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Tuesday, 28 February 2012

Hand hygiene 100% compliance at Ellis Hospitals. How did they do
that?

Mary Ellen Crittenden, Vice President of Quality at Ellis told us
that their board had a 'zero tolerance policy' for
non-compliance.

They had a huge focus on clinician buy
in and cultural issues developed over many months. They had 'secret shoppers' watching people and built it
up the tempo gradually to a stage where they then announced a 'three strikes and you are out'
policy.

If some one did not wash their hands:

first time - they
were sent home with pay
second time - they were sent home without
pay
third time - they were sent home and asked not to come back i.e.
sacked

As an aside they had the same policy for their employed and
visiting doctors, apparently they did not have to sack any of their more
than 1000 doctors

Of course not all their deployments to improve
quality were this harshly enforced.
Based on similar attitudes and healthcare lean methodology they have also achieved

495
continuous days without a single central line infection
0 - ZERO infections
for hip surgery in whole of 2010 and till April 2011

They are looking
forward to many other low or zeros soon (colonic surgery, caesarean
sections, etc)

When will we
see this here at our work place? Most of us sooner or later
are likely to end up as a patient in our local hospitals; well, it could happen
tomorrow. We have to get it sorted before we occupy one of these
beds!

Sunday, 12 February 2012

Homeostasis: The principle behind resistance to change. Doctors know all about it.

A software demo

In a session with a very enthusiastic innovator/early
adopter group of people passionate about improvement; my own relationship with
the group is they trust me but also find me intriguing; I offered the
participants a particular software; the features of the software are as
follows:

1) it was from a different producer and hence at a user level it
was different (but not greatly different) from what they essentially use every
day
2) it was at least 4 times quicker to switch on (pressing the button to
start working with it) - this was proven to the group right in front of their
eyes. It was also much quicker to shut down.
3) it does everything that their
existing software does and it does more (with a little effort it will also run their existing
software)
4) it is very stable - almost never crashes
5) it never gets a
virus (not known so far in common use at least)
6) it is completely free
(compared to £70 to £250 one off costs associated with their existing
software)

The group consisted of 11 people. One person in the group who
was already using it and vouched strongly for it.

Nobody (10 out of 10)
said they would change to it; one person out of 10 said in a very tentative and
cautious manner 'I would try it'. I have since tried with another group of nine
people where again only one person said 'I will try it out'. This was the
situation for a proven idea/software introduced by a 'trusted'
peer.

Change management

Change management is a huge
challenge. It is not just in the NHS alone (or may be it is) where we love or we
may not love but we will continue to do things that are slow, unstable,
complication prone and costly just because we are familiar with it (as an aside,
in the NHS anyone who is suspected of doing even mildly unfamiliar things will be accused of
behaving in a risky way). In this example of mine, it was only software - its
kind of okay. Do we do this in our clinical practice? Though all of us would
deny that, there is enough evidence that we show such unnecessarily resistant
behaviour and very importantly we are actively supported in such behaviour by
some of our authority holders.

There are specific ways of making changes
happen and proven methods in healthcare are already available. Many of us are
working on it. However, only when 8 out 10 people will be willing to hear, try
and change easily for the purpose of improving the safety and quality we provide
will be the day where we find Success in Healthcare!!

Change
Management and Homeostasis

The origins of this behaviour is far
deeper than we think. Most clinicians will be familiar with the concept of
homeostasis; human bodies are created to 'maintain' a stable environment for
themselves. If things are not working, the body restores it to get back to its
previous normality. It is possible to achieve a new/different level of
'normality' (whether it is positive e.g. body building or negative e.g. dietary
related obesity) even when there is nothing broken/ill, but for that the mind
and body needs to put in specific additional effort - most of the time our mind
and/or body does nothing of that kind (except of course in the case of children
where there is a continuous effort voluntary and involuntary to achieve an
improved status till they get to be adults). Further interestingly it is
possible to achieve a newer level of normality on the negative side with not
much effort at all but any positive change needs focused prolonged effort
(refer back to the examples of obesity versus body building); to get unfit does
not need effort, to get fit we need to work very hard.

In our work life,
we display similar individual and organisational behaviours. We get to work with
an explicit intention of doing a 'normal' days work. Fire-fighting - looking for
things that are broken so badly that it will stop us from functioning and
restore it to functional levels - we do that. We easily slip into bad habits and
behaviours (e.g. employing people to run a bad process rather than redesigning
the process) - we do that.

Only some of us take positive efforts to make
changes to improve the service. There could be problems in that. Imagine this
scenario - if our hospital was the equivalent of a relatively unhealthy human body and one particular organ, say the right arm
decided to improve itself by getting fit and muscular - we will have an unfit obese hospital with a well developed strong
muscular right arm. Now, is that normal or beautiful? Neither. So the right
arm gives up sooner or later surely encouraged by the rest of the body which
wants the right arm to 'fit in' with the majority.

How to resolve this issue?

Obviously if you are running an organisation and want to improve it you will be uncomfortable accepting a worsening scenario; justifying it by some logical argument about homeostasis would sound dubious. You may want to try to meaningfully measure the performance of various parts of your organisation and present it transparently. No one likes to be part of a worsening performance graph.

NB: I was comparing Ubuntu (Linux
based) operating system versus Microsoft Vista as exists in my laptop computer on a dual boot. For personal use, I have been mostly using Ubuntu
since January 2011 and have found it very good. Would you try
it?

PS: I have nothing against Microsoft which has served me well over
many years. As of date I have no vested interest in MS or Ubuntu or in any other software
company.

Sunday, 5 February 2012

'Complication' is
such a sanitised word. When doctors and nurses speak about complications the
language is purely technical, distant and mostly third party. When the
complication comes true, it is of course none of those, it is very personal;
physically and emotionally hurtful with huge trauma to to the sufferers and
their families, in so many ways that we can never understand or even describe.

The following is
about a series of extraordinary real life happenings that relates to a normal
British person from Portsmouth and his family. The words are a cut and paste
from the court judgement with a few minor changes to help normal reading.

The patient was aged 39. His father had for several years
been undergoing kidney dialysis treatment and was suffering from renal failure.
The patient was anxious to give his father the opportunity of a better quality
of life in his well earned retirement by donating his own right kidney, thus
sparing his father further dialysis treatment. The operation was performed on
26th February 2008. The hospital admits that the operation was
performed negligently, and to a degree recklessly. There are proceedings before
the General Medical Council against the surgeon in question.

The consequences of the hospital's negligence have been
catastrophic for the patient and his family: physically, psychologically,
emotionally and financially. Although the patient's right kidney was
successfully removed and transplanted, the patient suffered irreversible failure
of the left kidney. In fact he should never have been advised to undergo the
operation at all given the grave dangers involved. That negligent advice was
compounded by serial mistakes during the operation itself. The patient's life
was saved only after many hours on the operating table during which he received
over 100 units of blood and fluid transfusions.

During the course of the operation the patient suffered
further complications which have had far reaching consequences: a minor
myocardial infarction; ischaemic damage to the bundle of nerves known as the
lumbo-sacral plexus, which supply the right leg and foot; a thrombosis of the
inferior vena cava.

The patient was left in total renal failure. He was in
hospital for nearly two months, during which he started to receive
haemodialysis. He developed a serious drug induced confusional disorder. There
were further re-admissions to hospital in March and April 2008, following which
he received dialysis treatment three times a week as an outpatient for a year.
This treatment affected him profoundly. He became severely depressed, frequently
contemplating suicide. He contracted serious infections, one of which
necessitated a further admission to hospital for four days in October 2008.

The patient's own act of altruism and family devotion in
donating a kidney to his father, which cost him so dear, was reciprocated by the
patient's sister. With the same outstanding altruism and family devotion she in
turn donated a kidney to the patient, at very considerable psychological and
emotional cost. That operation, performed on 27th March 2009, was
successful. It released the patient from an indefinite regime of dialysis.
However, he lives with the constant fear that his body will reject the kidney
and it is common ground that when he reaches his early sixties that kidney will
require replacement. This uncertainty, and his experiences generally, have left
him with an understandable obsession about his health.

Unfortunately a recurrent infection was imported with his
sister's kidney, cytomegalovirus viraemia (CMV). This is a constant source of
worry. So is his blood creatinine level which, if raised, can be a sign of
kidney rejection.

The renal failure the patient suffered increases
significantly the risk that he will suffer from ischaemic heart disease and a
stroke. Consequently he adopts a very careful lifestyle and diet. He has had
high blood pressure and high cholesterol levels which cause him constant worry.
The immuno-suppressant drugs he takes, in particular to control the CMV, greatly
increase the risk of his developing other debilitating and life threatening
conditions. The consequence is that he has become fastidious to the point of
obsessional about personal and general hygiene, which impacts upon the whole
family. He can be irritable and overbearing. He is prone to bouts of weeping.

There are further serious physical consequences. The
nerve damage suffered during the negligent operation has resulted in altered
sensation below the right knee. There is hyper-sensitivity, pain and loss of
sensation in various parts of the right foot, and clawing of the first and
second toes. He has had surgery on the first toe. Further surgery had been
planned to straighten and fuse the toes but this drastic measure may be avoided
by regular injection of botulinum toxin for life. The issue surrounding this
problem with his foot has a bearing on his residual earning capacity. Currently
he is unable to run, and walking on uneven ground and stairs presents some
difficulty.

The patient has also been much distressed by urinary
difficulties. For a time self- catheterisation was attempted. He found it a
dreadful experience. Urinary frequency bedevils his daily life, and results in
broken nights for him and for his wife.

The medication he takes has had unpleasant side-effects
including the profuse growth of unwanted body hair, the development of skin
acneiform lesions and the deposit of facial and abdominal fat. His inability to
exercise has also led to undesirable weight gain. Prior to the operation, the
patient was a healthy, fit and active 35 year old man. He took great pride in
his health and fitness, running several kilometres each morning to set himself
up for the working day. He had enormous energy. He was cheerful, optimistic and
extrovert.

Now the picture is very different. At the age of 39 his
daily life revolves around his health worries. He is constantly fearful of
infection or changes which may increase the risk of the kidney being rejected.
Any venturing from the strictly enforced hygiene of the home is fraught with
anxiety. He lives with the certain knowledge that the kidney will require
replacement by the time he reaches the age of 61 and that this will be preceded
by symptoms of progressive renal failure. It is agreed that his life expectancy
has been reduced by 10 years.

The patient's wife
says that the patient is a shadow of his former self. He is lacking in energy.
He is exhausted by 9 pm and generally has to be in bed by 10 pm. He is moody and
irritable. Their marriage, though very strong, is constantly under strain. The
children have been affected and distressed by their father's condition and
behaviour and he has bridges to build there.

-----------------End of cut and
paste------------------------------

The above example
was of course extraordinary, further the issue reached the court of law
otherwise we would not have heard it in such a profound and full sense. It might
have reached us through the press in which case we would have discounted it for
journalistic embellishment. In reality most if not every healthcare related
'complication' has impacts on patients' lives which are significant but we will
never hear about it.

Perhaps it is time
to start describing some of the possible known effects of complications on
patient's lives should be described in a way that it really affects patients
lives. Let me explain. Do you think the hospitals, doctors or nurses when
explaining or consenting patients for surgery ever tell them 'if you had one
of the severe complications your marriage could be constantly under strain; your
children could be affected and distressed by your condition and behaviour and
your may need bridges to be built with them as a
result''?

For instance When
we talk about surgery on blood vessels in the limb we mention 'amputation' as a
possibility. Does that really describe anything to a patient who has never
experienced or seen amputation before? Perhaps we ought to tell them how in the
initial days even to move from side to side in a bed they would need support,
their entire body will need to put in daily heroic effort to cope, they will not
be able to do any sort of work for many months, if everything goes well it will
hurt during wound healing, during dressing change, during physio, during limb
fitting, when using the limb. When goes wrong it will hurt more, more often and
for longer – if it goes wrong even more it will hurt every day of their lives
(phantom limb pain). They will need to know that the pain will need strong pain
killers, strong pain killers will cause constipation, constipation could cause
fissure which will hurt even more. They would need to know that if the wound
breaks down their raw cut bone could stick out. Well, even after these
descriptions we haven’t even made a start on the long list and impacts in a
proper way!! These are only physical.

Perhaps we need to
tell them that they may not be able to drive a normal car; the pain could drive
them to become an alcoholic if they are lucky and a drug addict if they are
unlucky. Perhaps they need to know that their family and friends will provide
sympathy which the patient could misinterpret and end up feeling patronised resulting in
phenomenally strained relationships all around.

God help us avoid
complications.

Complications are
true complications only when every effort at our command is made
to avoid them from happening and yet they happened, otherwise it cannot be
called a complication; it is called harm. As an illustration, if a patient
developed deep vein thrombosis due to omitted drug thromboprophylaxis, poor
mobilisation, poor hydration or pelvic injury at surgery that DVT is healthcare
caused harm; similarly if a spinal or epidural catheter was removed without
regard to when chemical thromboprophylaxis was given and the patient developed
spinal cord problems, that would be harm caused by heal. DVT prevention is an
easy example, there are thousands of other ways that healthcare's omissions,
commissions and disagreements hurt patients; they can no longer be
euphemistically called complications any longer.

Here is something
uncomfortable, a number of these problems happen because of us (organisation or individuals) though we are often unable to even recognise that.

Once again, the
impacts of complications on peoples lives is something that healthcare
professionals would not be able to even begin to understand, or describe. There
are specific tried and tested methods to avoid harm or to reduce them to their
minimum possible. Most healthcare providers do not have to do world beating
cutting edge stuff, they only have to put in some effort to just avoid harm in
healthcare. If it was done that would count as Success in Healthcare.